Health Questionnaire
A
1. Do you need glasses to read?
2. Do you need glasses to see things at a distance?
3. Has your eyesight often blacked out completely?
4. Do your eyes continually blink or water?
5. Do you often have bad pains in your eyes?
6. Are your eyes often red or inflamed?
7. Are you hard of hearing?
8. Have you ever had a bad running ear?
9. Do you have constant noises in your ears?
B
10. Do you have to clear your throat frequently?
11. Do you often feel a choking lump in your throat?
12. Are you often troubled with bad spells of sneezing?
13. Is your nose continually stuffed up?
14. Do you suffer from a constantly running nose?
15. Have you at times had bad nose bleeds?
16. Do you often catch severe colds?
17. Do you frequently suffer from heavy chest colds?
18. When you catch a cold‚ do you always have to go to bed?
19. Do frequent colds keep you miserable all winter?
20. Do you get hay fever?
21. Do you suffer from asthma?
22. Are you troubled by constant coughing?
23. Have you ever coughed up blood?
24. Do you sometimes have severe soaking sweats at night?
25. Have you ever had a chronic chest condition?
26. Have you ever had T.B. (Tuberculosis)?
27. Did you ever live with anyone who had T.B.?
C
28. Has a doctor ever said your blood pressure was too high?
29. Has a doctor ever said your blood pressure was too low?
30. Do you have pains in the heart or chest?
31. Are you often bothered by thumping of the heart?
32. Does your heart often race like mad?
42. Are you troubled by bleeding gums?
43. Have you often had severe toothaches?
44. Is your tongue usually badly coated?
45. Is your appetite always poor?
46. Do you usually eat sweets or other food between meals?
47. Do you always gulp your food in a hurry’?
48. Do you often suffer from an upset stomach?
49. Do you usually feel bloated after eating?
50. Do you usually belch a lot after eating?
51. Are you often sick to your stomach?
52. Do you suffer from indigestion?
53. Do severe pains in the stomach often double you up?
54. Do you suffer from constant stomach trouble?
55. Does stomach trouble run in your family?
56. Has a doctor ever said you had stomach ulcers?
57. Do you suffer from frequently loose bowel movements?
58. Have you ever had severe bloody diarrhea?
59. Were you ever troubled with intestinal worms?
60. Do you constantly suffer from bad constipation?
61. Have you ever had piles (rectal hemorrhoids)?
62. Have you ever had jaundice (yellow eyes and skin)?
63. Have you ever had serious liver or gall bladder trouble?
E
64. Are your joints often painfully swollen?
65. Do your muscles and joints constantly feel stiff?
66. Do you usually have severe pains in the arms or legs?
67. Are you crippled with severe rheumatism (arthritis)?
68. Does rheumatism (arthritis) run in your family?
69. Do weak or painful feet make your life miserable?
70. Do pains in the back make it hard for you to keep up with your work?
71. Are you troubled with a serious bodily disability or deformity?
F
72. Is your skin very sensitive or tender?
73. Do cuts in your skin usually stay open a long time?
74. Does your face often get badly flushed?
75. Do you sweat a great deal even in cold weather? .
76. Are you often bothered by severe itching?
77. Does your skin often break out in a rash?
78. Are you often troubled with boils?
G
89. Have you at times had a twitching of the face or head?
90. Did you ever have a fit or convulsion (epilepsy)?
91. Has anyone in your family ever had fits or convulsions (epilepsy)?
92. Did you bite your nails badly?
93. Are you troubled by stuttering or stammering?
94. Are you a sleep walker?
95. Are a bed wetter?
96. Were you a bed wetter between the ages of 8 and 14?
H – FEMALES
97. Have your menstrual periods usually been painful?
98. Have you often felt weak or sick with your periods?
99. Have you often had to lie down when your periods came on?
100. Have you usually been tense or jumpy with your periods?
101. Have you ever had constant severe hot flashes and sweats?
102. Have you often been troubled with vaginal discharge?
103. Do you have to get up every night and urinate?
104. During the day‚ do you usually have to urinate frequently?
105. Do you often have severe burning paw when you urinate?
106. Do you sometimes lose control of your bladder?
107. Has a doctor ever said you had kidney or bladder disease?
H – MALES
97. Have you ever had anything seriously wrong with your genitals (privates)?
98. Are your genitals often painful or sore?
99. Have you ever had treatment for your genitals?
100. Has a doctor ever said you had a hernia (rupture)?
101. Have you ever passed blood while urinating (passing water)?
102. Do you have trouble starting your stream when urinating?
103. Do you have to get up every night and urinate?
104. During the day‚ do you usually have to urinate frequently?
105. Do you often have severe burning pain when you urinate?
106. Do you sometimes lose control of your bladder?
107. Has a doctor ever said you had kidney or bladder disease?
I
108. Do you often get spells of complete exhaustion or fatigue?
109. Does working tire you out completely?
110. Do you usually get up tired and exhausted in the morning?
111. Does every little effort wear you out?
112. Are you constantly too tired and exhausted even to cat?
113. Do you suffer from severe nervous exhaustion?
114. Does nervous exhaustion run in your family? . 122. Are you always ill and unhappy?
123. Are you constantly made miserable by poor health?
K
124. Did you ever have scarlet fever?
125. As a child‚ did you have rheumatic fever‚ growing pains or twitching of the limbs?
126. Did you ever have malaria?
127. Were you ever treated for severe anemia (thin blood)?
128. Were you ever treated for “bad blood” (venereal disease)?
129. Do you have diabetes (sugar disease)?
130. Did a doctor ever say you had a goiter (in your neck)?
131. Did a doctor ever treat you for tumor or cancer?
132. Did you suffer from any chronic disease?
133. Are you definitely under weight?
134. Are you definitely over weight?
135. Did a doctor ever say you had varicose veins (swollen veins) in your legs?
136. Did you ever have a serious operation?
137. Did you ever have a serious injury?
138. Did you often have small accidents or injuries?
L
139. Do you usually have great difficulty in falling asleep or staying asleep?
140. Do you find it impossible to take a regular rest period each day?
141. Do you find it impossible to take regular daily exercise?
142. Do you smoke more than 20 cigarettes a day?
143. Do you drink more than six cups of coffee or tea a day?
144. Do you usually take two or more alcoholic drinks a day?
Note. The male and female versions of the HQ are identical except for section H.
This instrument can be found at: http://www.emcdda.europa.eu/html.cfm/index3651EN.html
Yes‚ NO
Brodman‚ K.‚ Erdmann‚ A.J.‚ Lorge‚ I.‚ & Wolff‚ H.G. (1949). The Cornell Medical Index: An adjunct to medical interview. Journal of the American Medical Association‚ 140‚ 530-534. Kenneth Brodman‚ M.D.